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Found 794 results
  1. Content Article
    The Peer Network for Advancing Equity through Quality and Safety is a year-long program offered by the Center for Health Equity at the American Medical Association (AMA) in collaboration with the Brigham & Women’s Hospital (BWH) and The Joint Commission (TJC). It is designed to help health systems apply an equity lens to all aspects of quality and safety practices and improve health outcomes for historically marginalised populations. This article covers the program's strategic plan, goals and activities and includes embedded videos containing an introduction to the program and a simulated case review.
  2. Content Article
    This webinar hosted by the National Orthopaedic Alliance (NOA) gives a brief overview of human factors and ergonomics, its relevance and role in improving patient safety, how it has been embedded in one organisation and the impact it has had. Fran Ives, Human Factors Specialist and part of the Human Factors team at the Robert Jones and Agnes Hunt Hospital (RJAH) speaks about her experience of applying Human Factors both within a large NHS Trust and an Academic Health Science Network, including the successes and challenges of setting up and developing a service, and what difference such a service can make.
  3. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Sharon talks to us about why manual handling needs to be more than tick-box training, and describes its significance for patient safety.
  4. Content Article
    In this blog for the cross-party think tank Policy Connect, the Professional Standards Authority for Health and Social Care sets out its view on the biggest challenges affecting the quality and safety of health and social care outlined in its report Safer care for all - solutions from professional regulation and beyond. It describes gaps in the wider framework to protect the public highlighted in this report and considers where Parliament and the Government have an opportunity to act to support safer care for all. Related reading Patient Safety Learning: Joining up a fragmented landscape: Reflections on the PSA report ‘Safer care for all’ (12 September 2022) Working together to achieve safer care for all: a blog by Alan Clamp (12 September 2022)
  5. Content Article
    Mersey Care Foundation Trust's development of a respect and civility agenda has been shortlisted for several national awards. They have developed a free course called Just and Learning Culture: A New Way of Caring, which is aimed at HR colleagues but is accessible to everyone. You can read more about their work, and access the course (scroll to the bottom of the page) via the link below.
  6. Content Article
    Always Events are defined as “those aspects of the patient and family experience that should always occur when patients interact with healthcare professionals and the health care delivery system”. NHS England has been leading an initiative for developing, implementing, and spreading an approach to reliably integrate Always Events into routine frontline services. Always Events® is a co-production quality improvement methodology which seeks to understand what really matters to patients, people who use services, their families and carers and then co-design changes to improve experience of care. Genuine partnerships between patients, service users, care providers, and clinicians are the foundation for co-designing and implementing reliable solutions that transform care experiences with the goal being an “Always Experience.” This webpage contains: information on the Always Events national programme Always Events toolkit Evaluation of Always Events Always Events film
  7. Content Article
    Safety conversations are an important step in building a proactive patient safety culture. They’re a respectful discussion about safety between two or more people involved in organising, delivering, and seeking or receiving care. This collection of tools and resources, from quick tip sheets to comprehensive reports and frameworks, aims to help healthcare professionals to have effective safety conversations and support safer care of older adults.
  8. Content Article
    This download is the second of three chapters of a book which complements the Chartered Institute of Ergonomics and Human Factors' Healthcare Learning Pathway and is intended as a practical resource for students.
  9. Content Article
    Making Families Count aims to improve outcomes for families affected by serious harm and traumatic bereavements in health and social care services. They offer peer support, training, information, advice and guidance to families who have suffered a traumatic bereavement. They also provide independent training in the importance of good family engagement for NHS Trusts, public health and social and care organisations. The training includes working with families after serious incidents, developing Family Liasion work, good engagement throughout treatment and developing resilience for professional staff. The charity's vision is that the NHS, social care and other public bodies will make families count by ensuring that families are integral to health and social care investigations, leading to better investigations, better learning, safer services and the right support for families.
  10. Content Article
    This report by the National Medical Examiner, Dr Alan Fletcher, summarises the progress made by medical examiner offices in 2021 and outlines areas of focus going forward. It highlights that medical examiners continued to receive positive feedback from bereaved people—many said they appreciated being given the opportunity to have a voice in the processes after a death and knowing any concerns were listened to. It includes information on: The national medical examiner system Implementation Guidance and publications Training Stakeholders Increasing the number of non-coronial deaths scrutinised Feedback received by medical examiners in England and Wales
  11. Content Article
    This webpage outlines the role of Medical Examiner Officers (MEOs), who provide the continuity and oversight that the medical examiner service requires to have the maximum benefit. It includes information on training, induction and recruitment, as well as a model job description for an MEO.
  12. Content Article
    This research is a collaboration between the NHS AI Lab and Health Education England. Its primary aim is to inform the development of education and training to develop healthcare workers’ confidence in artificial intelligence (AI).
  13. Content Article
    This report explores the factors influencing healthcare workers’ confidence in AI-driven technologies. A second report will detail how their confidence can be developed through education and training.
  14. Content Article
    This study in the SA Journal of Human Resource Management aimed to develop a conceptual framework that identifies the critical success factors that affect the implementation of team coaching in organisations. The results indicate that to integrate successful team coaching into any organisation, effective analysis of an organisational context is required. This includes leadership stakeholders, team effectiveness, competency of a coach and employee engagement. The study also identified constraints that may prevent successful implementation of team coaching.
  15. Content Article
    World Menopause Day is held every year on 18 October to raise awareness of the menopause and the support options available for improving health and wellbeing. In this blog, I want to raise awareness of surgical menopause, which affects over 4000 young women a year, specifically around the lack of information and support received before and after surgery.  
  16. Content Article
    This letter to the editor published in The Journal of Biomedical Research outlines the ways in which simulation will be used in medical education in the future. The author highlights that: simulation is likely to become much more closely linked to assessment in the future. our vision of what constitutes simulation will change radically in the future, with access to simulation becoming easier and wider. the future of simulation in medical education will follow the same path as the future of healthcare—more primary care, management of long term conditions and patient self-management.
  17. Content Article
    Simulation is a training technique that replaces real experiences with guided experiences. These experiences replicate substantial aspects of the real world in a fully interactive manner. This article looks at the future of simulation in healthcare, categorising applications of simulation into 11 dimensions: The purpose and aims of the simulation activity The unit of participation in the simulation The experience level of simulation participants The healthcare domain in which the simulation is applied The healthcare disciplines of personnel participation in the simulation The type of knowledge, skill, attitudes of behaviour addressed in simulation The age of the patient being simulated The technology applicable or required for simulations The site of simulation participation The extent of direct participation in simulation The feedback method accompanying simulation
  18. Content Article
    This article looks at the enormous growth in the use of clinical simulation that has happened over the last 20 years, examining why simulation is an effective tool in training healthcare professionals and how it can be applied to different healthcare topics and settings. The authors look at the history of simulation in medical training, theories related to simulation, the typology of simulation, the importance of simulation education during the Covid-19 pandemic and current trends and innovation in simulation education.
  19. Content Article
    Nursing education has long utilised simulation in different forms to teach the principles and skills of nursing care, from anatomical models to computer-based learning. This chapter from Patient Safety and Quality: An Evidence-Based Handbook for Nurses looks at simulation training as a strategy to prevent healthcare errors. It explores the value of human patient simulation in nursing education programs.
  20. Content Article
    This document outlines how Health Education England (HEE) hopes to expand the role of simulation and immersive learning technologies in the education and training of the NHS workforce. Simulation is defined as ‘a technique to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully safe, instructive and interactive fashion’. This document considers how existing techniques and technologies can benefit wider policy and strategy goals in health and care, outlining HEE's intention to: promote and strengthen the dialogue between different system and stakeholder organisations, networks, and communities to enable and evaluate opportunities for sharing intelligence and innovation provide a platform for collaboration on common themes of work generate evidence of impact that will help support the transformation in health and care that is required for the future needs of patients and society.
  21. Content Article
    Develop your understanding of your own health and wellbeing to better lead and support your colleagues, and organisation in this King's Fund online course delivered over 3 weeks.
  22. Content Article
    Preventable harm, from the systems of care intended to improve health, continues to occur at an unacceptable rate in the United States. Healthcare systems have an opportunity to learn and improve from each episode of preventable harm. Accordingly, every preventable patient death or injury must energise our efforts to prevent future patient harm. The Anesthesia Patient Safety Foundation (APSF) believes that criminal prosecution of healthcare providers will make the work of preventing harm more difficult since it continues to shift the focus away from system improvements. They have released a position and policy statement outlining the rationale for opposing criminal prosecution and, equally important, recommends that all healthcare systems and organisations aggressively act, now, to improve their culture, processes, and training to reduce errors of all kinds and, specifically in light of recent events, medication errors. Some specific actions are recommended as examples of what can be done. Individual healthcare professionals should be mindful of their role in preventing errors and reporting errors that occur as well as taking action to encourage and enable their organization to improve the flaws in the systems in which they work that lead to harm to patients.
  23. Content Article
    This programme from the Advancing Quality Alliance (Aqua) provides participants with the tools, skills and knowledge to oversee the successful implementation of a safety culture survey in organisations. Participants of this programme will develop a working knowledge of safety culture theory and the Agency for Healthcare Research and Quality (AHRQ) safety culture survey alongside the support that Aqua provides to enable deployment and analysis of the survey. This programme links directly to Aqua’ safety offers, including Psychological Safety, Human Factors and Improvement Practitioner programmes.
  24. Content Article
    On 23 April 2020 Jaqueline Lake commenced an investigation into the death of Eliot Harris aged 48. Eliot had schizophrenia and diabetes. Eliot had not been taking medication for several days and his condition deteriorated. He was admitted to Northgate under the Mental Health Act after assessment on 5 April. He was initially in seclusion then on the ward from 6 April, he spent a lot of time in his room and only ate cheese sandwiches. He only accepted medication in intramuscular form and on 9 April by depot injection. His physical observations were recorded as being normal, and a blood test on 7 April showed he did not have diabetes. His intake of food and fluid remained minimal but he was not put on a chart to monitor this. Staff last entered his room at 17:46 on 9 April. He was last seen conscious at 18:10 on 9 April. He was found unresponsive at 01:33 and declared dead at 02:00.  The investigation concluded at the end of the inquest on 8 August 2022. Medical cause of death: 1a) Unascertained Conclusion: Open – the evidence does not reveal the means by which Eliot Harris came by his death.
  25. Content Article
    On 24 October 2019 coroner Lydia Brown commenced an investigation into the death of Asher William Robert Sinclair, age 3. The investigation concluded at the end of the inquest on 24 January 2022. The conclusion of the inquest was: His medical cause of death was: 1a Hypoxic ischaemic brain injury 1b out of hospital cardiac arrest 1c displaced tracheal tube (trachael tube dependant) II Neonatal enterviral myocarditis and encephalitis (trachael ventilator dependant and cardiac pacemaker). Asher died on 8th October 2019 in Great Ormond Street hospital when his life support mechanisms were withdrawn.
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